One of the newer elaborated categories in the DSM-V (2005) is called “somatic symptom disorder.” According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), somatic symptom disorder (SSD) involves one or more physical symptoms accompanied by an excessive amount of time, energy, emotion, and/or behavior related to the symptom that results in significant distress. While there are many forms of “somatic” disease, most disability insurers describe it as “it’s all in their head.”
Hypochondria, is defined as a debilitating condition resulting from an inaccurate perception of the condition of the body, or mind, despite the absence of an actual medical diagnosis.In fact, to this day Fibromyalgia and CFS are still considered to be “somatic” and are labeled as a “syndrome” since there are no tests to prove one has what they say they have.
Not too far behind is “Malingering“, which is the deliberate avoidance of work or activity for secondary gain. (Disability claim interpretation.) Next, is Conversion Disorder, also known as Functional Neurological Symptom Disorder (FND), is a psychiatric disorder characterized by symptoms affecting sensory or motor function. These signs and symptoms are inconsistent with patterns of known neurologic diseases or other medical conditions. Many years ago, a Unum claimant identifying as a snake charmer was diagnosed with< FND and her claim was denied even though she was in a wheelchair./p>
The purpose of this article is not to “go into” each one of the somatic assumptions, but to give you more information about how disability insurers “use” somatic illness to deny claims. Since the DSM-V created an entire section for presumed “somatic” illness, insurance companies are backed-up by an unquestionable source of psychiatric information.
In many ways, the DSM-V suggests that every illness has a “mental” or psychiatric component to it. For example, insurers have long said that FMS and CFS represent dual diagnoses containing both a physical AND mental component. Appropriate treatment then would be with both a rheumatologist and a therapist, or psychiatrist.The DSM-V gave insurers the back-up they needed to deny claims at 24 months for mental illness, despite the fact that insureds also reported physical disease.
Exaggerating symptoms isn’t new to the insurance industry at all, which in all fairness is why insurers often require what they do. A headache that could be worked through a month ago, suddenly becomes a crushing migraine, or, back pain that was manageable with Advil suddenly become unbearable. I’m not suggesting this can’t happen, but when reported, disability insurers will go nuts investigating “what changed”. This is why we’re still seeing this question contained in letters from insurance companies.
Malingering on the other hand is usually “found out” by reading physician’s notes, and discovering the doctor’s reluctance to document restrictions and limitations, or very good ones at any rate. The physician tries to stay on the fence, doesn’t want to “document functional capacity” etc. Do people really file for disability because they don’t want to work? I can tell you, “yes, they do”, and in most instances, their physicians know it too!
You may be thinking this doesn’t happen all that much, but in the mid 70’s to 80’s the entire insurance industry was nearly brought to its knees. The development of the Individual Disability Income (IDI) “own occupation” policy was based on the premise that PROFESSIONALS, such as doctors, dentists, top executives would NOT file fraudulent, or secondary gain claims. Sales of the own occupation IDI policy reached in the billions. And then……………
It all collapsed. Why? Alternative health insurance, namely the HMO and PPO were developed. These types of insurance plans capped fees and services for physicians who as a result…..all went out on disability under their “better than sliced bread” own occupation policies. Physicians, dentists, lawyers, highly paid executives alleged they were “unable to perform their own occupation”, and the volume nearly broke the back of the insurance industry.Several insurers actually did go out of business.
Maybe you can understand the how and the why insurers “risk manage” the way that they do. The ERISA folks, statistically around 15% of all submitted claims are documented in some way as either malingering, secondary gain, reporting somatic symptoms etc. It is indeed unfortunate that the “honest” and “fair dealing” body of insureds and claimants are victims of a system dedicated to finding the 15% and denying their claims.
Managing a disability claim is much more than sending in paperwork and hoping for the best. Everything about a disability claim is how insureds, “honestly position, report and document the facts of their claims. Not everyone knows how to do that. There is much more to “risk management” than you know.
If anything, I hope you’ve found this article interesting. Please let me know by emailing your feedback to me.
